1
CHALLENGES FACING THE DHS presentation to the
NATIONAL PORTFOLIO FOR HEALTH COMMITTEE
MEETING 20 June 2003 Peter Barron

2
BackgroundFragmentation Duplication
Dr J Cupido, Chief Director Mental and Rural
Regional Health Services

• 1977 Health Act permitted National, Provincial
  Local Government to duplicate services. See Act
• 1994 National-Provincial overlap addressed
• Powers Functions defined Major Restructuring
  (9 Provinces)
• 2003 still Provincial-Local government overlap
  regarding Functions/Powers
• Constitution
• MHS an exclusive function of LG
• MHS not defined

Provincial Government Western Cape / Department
of Health
3
Conceptually Macro process
Dr J Cupido, Chief Director Mental and Rural
Regional Health Services
Quality, Integrated, Comprehensive PHC PHC
approach
Fragmented Selective PHC
District Health System
Provincial Government Western Cape / Department
of Health
4
Implications
Dr J Cupido, Chief Director Mental and Rural
Regional Health Services

• DMs must take over from Provinces LMs ( must
  expand in rural areas), financial responsibility
  for environmental health services
• A funding for this must be identified
• Provinces must take financial responsibility for
  full equitable funding of all other PHC
  services
• Transitional arrangements are needed to avoid
  services being run down or collapsing

Provincial Government Western Cape / Department
of Health
5
Overall funding picture (2001/02)
Dr J Cupido, Chief Director Mental and Rural
Regional Health Services

• Provincial direct financing R4.1bn
• Provincial Transfers to LG R0.7bn
• L Government Own Revenue R1.0bn
• Limited financial decentralisation
• Large inequities-Provinces R75-246 per capita
  District R42-R389 per capita
• National service level package costed
• Shortfall against norm approx R1.2billion
  overall-metro vs non metro
• Implications for replacement funding for function
  shift

Provincial Government Western Cape / Department
of Health
6
CHALLENGES

• LEGISLATION
• GOVERNANCE
• EQUITY
• HUMAN RESOURCES DEVELOPMENT
• IMPROVING QUALITY OF CARE

7

LEGISLATION -UNCERTAINTY ABOUT
IMPLEMENTATION WHEN HOW DIFFERENT PROVINCES
DOING DIFFERENT THINGS -COMMUNICATION
8
GOVERNANCE-DISTRICT HEALTH
COUNCILS COMPOSITION METRO AREAS CROSS
BOUNDARY AREAS-FUNCTIONING BUREAUCRACY UNDERST
ANDING OF BUDGET
9
EQUITY-DIFFERENT PROVINCES SPEND DIFFERENT
AMOUNTS ON PRIMARY CARE-DIFFERENCES WITHIN
PROVINCES-SERVICES ARE PROVIDED DIFFERENTLY IN
URBAN AND RURAL AREAS (compare district hospitals
with midwife obstetric units)
10
Provincial Health Expenditure (PHC)
Dr J Cupido, Chief Director Mental and Rural
Regional Health Services
Table 5.13 Primary Health care expenditure Table 5.13 Primary Health care expenditure Table 5.13 Primary Health care expenditure Table 5.13 Primary Health care expenditure Table 5.13 Primary Health care expenditure
2002/03 2002/03 2003/04 2003/04
R million Estimated actual Rand per capita Budget Rand per capita
Eastern Cape 592 91 703 106
Free State 425 183 396 168
Gauteng 1,138 238 1,183 243
Kwa-Zulu Nata 1,1288 163 1,392 174
Limpopo 378 70 417 75
Mpumalanga 328 122 405 148
North West 139 199 174 246
Northern Cape 456 145 548 172
Western Cape 654 213 738 237
Total 5,398 148 5,955 160
Provincial Government Western Cape / Department
of Health
11
HUMAN RESOURCES-ABSOLUTE SHORTAGE OF
NUMBERS-NO CLEAR HUMAN RESOURCE DEVELOPMENT
PLAN -HIV SKILLS-DATA USAGE
SKILLS-MANAGERIAL SKILLS
12
IMPROVING QUALITY OF CARE-HIV-REALISTIC
TARGETS (e.g. TB cure rates, infant mortality
rates)-PRIORITISATION (Basics need to be in
place first)-SUPERVISION AND SUPPORT
13
Restructuring PHC services
Dr J Cupido, Chief Director Mental and Rural
Regional Health Services

• Municipal Health Services defined
• Function allocated to A C municipalities
• Provinces responsible for planning funding all
  other PHC services
• But can delegate provision to municipalities
• And municipalities can contribute funds
• BUT still need to resolve how to achieve equity
  in funding and provision

Provincial Government Western Cape / Department
of Health
14
TAKE HOME MESSAGES

• CROSS-BOUNDARY DISTRICTS NEED SPECIAL ATTENTION
• CLEAR COMMUNICATION CHANNELS BETWEEN PROVINCES
  AND LOCAL GOVT. REQUIRED
• MANAGEMENT TEAMS NEED TO BE IN PLACE WITH
  PERMANENT POSITIONS
• PROVINCES NEED TO GIVE EXTRA SUPPORT TO THESE
  TEAMS
• MEETINGS AT PROVINCE SHOULD BE SCHEDULED, NOT AD
  HOC

15
TAKE HOME MESSAGES

• Information management needs improvement
• If you want to improve health status in your
  province focus on those areas with the worst
  indicators as biggest gains can be made
• Within districts there are variations and thus
  focus on sub-districts, and even facilities which
  are far below the average
• Encourage those above the average to set improved
  targets for themselves

16
TAKE HOME MESSAGES

• Regular and supportive supervision is required
• Districts need to be given specific areas of
  focus and not told to improve PHC
• National programmes need to work with provincial
  counterparts and go to the districts to support

17
The end